SLEEP APNEA SYNDROMES (OBSTRUCTIVE CENTRAL MIXED)

STEVEN D. REISS · 2026 · Case ID: 26003841

GRANTED

Summary

The veteran, who served in the U.S. Army from October 1978 to October 1981, appeals the denial of service connection for obstructive sleep apnea (OSA) and insomnia. The veteran claims these conditions are secondary to his service-connected low back disability, with obesity as an intermediary step. He also contends his OSA began in service after a back injury and is due to toxic exposure at Fort Lewis. During a December 2025 hearing, the veteran testified about his in-service back injury and subsequent sleep issues, including snoring reported by fellow servicemen. He also noted his current pain limits exercise and his worry about not using a CPAP machine. The Board found the private medical opinion from December 2025 to be the most probative evidence. This opinion linked the veteran's OSA to his service-connected low back disability and obesity, citing studies showing a strong association between chronic spinal pain, obesity, and OSA. The Board found the VA examiner's opinion less persuasive, as it attributed OSA primarily to obesity and lifestyle choices, downplaying the link to service-connected conditions. The Board applied the benefit of the doubt doctrine, finding the evidence in approximate balance in the veteran's favor, and granted service connection for OSA as proximately due to his service-connected low back disability. For insomnia, the Board found the veteran's testimony credible and the evidence in approximate balance, granting service connection as proximately due to his service-connected low back disability.

Rationale

Private opinion found OSA proximately due to service-connected low back disability with obesity as intermediary step.; VA opinion found OSA less likely than not due to service-connected back disability, citing obesity and age as primary factors.; Board found private opinion more probative due to detailed rationale and review of record.; Benefit of the doubt doctrine applied due to approximate balance of evidence.

Service Branch

ARMY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

19-32 008A

Full Decision Text

Citation Nr: 26003841
Decision Date: 03/26/26 Archive Date: 03/26/26

DOCKET NO. 19-32 008A
DATE: March 26, 2026

ORDER

Service connection for a respiratory disability, diagnosed as obstructive sleep apnea (OSA), is granted.

Service connection for psychiatric disability, diagnosed as insomnia, is granted.

FINDINGS OF FACT

1. The evidence favors a finding that the Veteran's obstructive sleep apnea (OSA) is proximately due to and caused by his service-connected low back disability.

2. The evidence favors a finding that the Veteran's insomnia is proximately due to and caused by his service-connected low back disability.

CONCLUSIONS OF LAW

1. The criteria for entitlement to service connection for obstructive sleep apnea have been met. 38 U.S.C. §§ 1131, 1154(a), 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310.

2. The criteria for service connection for insomnia have been met. 38 U.S.C. §§ 1131, 1154(a), 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty with the United States Army from October 1978 to October 1981.

This matter is before the Board of Veterans' Appeals (Board) on appeal of a February 2018 rating decision of the Department of Veterans Affairs (VA).

In August 2024, the Veteran testified before the undersigned Veterans Law Judge.

In a January 2025 decision, the Board granted service connection for a bilateral knee disability, a right ankle disability, and a low back disability.

The Board also found that the issue of service connection for sleep disability, to include insomnia and obstructive sleep apnea, as a manifestation of or due to the Veteran's low back disability, had been raised by the record and added to the issues on appeal. Bailey v. Wilkie, 33 Vet. App. 188, 200-201 (2021); Morgan v. Wilkie, 31 Vet. App. 162, 167-68 (2019). The Board then remanded the claim for further development.

In December 2025, the Veteran again testified at a hearing held before the undersigned Veterans Law Judge.

Service Connection

Service connection may be granted for a disability resulting from disease or injury incurred or aggravated during active military service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Disorders diagnosed after discharge will be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d).

Generally, service connection requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004).

Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Service connection on a secondary basis is warranted for any incremental increase in disability, regardless of its permanence. See Ward v. Wilkie, 31 Vet. App. 233 (2019). Secondary service connection may be granted where a non-service-connected disability would have been less severe but for a service-connected disability. Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023) (invalidating the requirement of "proximate cause" and instead held a "but for" causation or aggravation is enough to show entitlement to secondary service connection).

Lay evidence, if competent and credible, may serve to establish a nexus in certain circumstances. See Davidson v. Shinseki, 581 F.3d 1313 (2009) (noting that lay evidence is not incompetent merely for lack of contemporaneous medical evidence). When considering whether lay evidence may be competent, the Board must determine, on a case-by-case basis, whether the Veteran's particular
service-connected disability. Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023) (invalidating the requirement of "proximate cause" and instead held a "but for" causation or aggravation is enough to show entitlement to secondary service connection).

Lay evidence, if competent and credible, may serve to establish a nexus in certain circumstances. See Davidson v. Shinseki, 581 F.3d 1313 (2009) (noting that lay evidence is not incompetent merely for lack of contemporaneous medical evidence). When considering whether lay evidence may be competent, the Board must determine, on a case-by-case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue.").

As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996).

The Board additionally notes that, if the Board requires assistance in understanding or interpreting the underlying medical text evidence, it may seek clarification from the medical expert who wrote the opinion or from another source. However, the Board is capable of interpreting medical text evidence on its own and is also able to interpret medical opinion evidence. McCray v. Wilkie, 31 Vet. App. 243, 249 (2019).

In McCray, the Court highlighted that, when evaluating medical text evidence and medical opinion evidence as to an unsettled medical question, it must bear in mind the reasonable doubt doctrine. Id. at 258 (citing Quirin v. Shinseki, 22 Vet. App. 390, 395 (2009)). Further, the Court noted that a medical principle need not reach scientific consensus to adequately support a grant of VA benefits. Id. at 258 (citing Wise v. Shinseki, 26 Vet. App. 517, 532

When the evidence is in approximate balance in the Veteran's favor or nearly equal regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990); Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc).

1. Service connection for obstructive sleep apnea (OSA) is granted.

The Veteran seeks service connection for OSA as secondary to his low back disability. Alternatively, the Veteran contends that his OSA first started in service after his back injury and has continued since then. Lastly, the Veteran stated that his OSA is due to his toxic exposure at Fort Lewis.

During the December 2025 Hearing, the Veteran testified that, during active service, he fell, hurt his back, and then, subsequently during service, was told by fellow servicemen that he was snoring. The Veteran stated that he has been dealing with these sleep problems ever since service. The Veteran testified that he weighed less in service and, due to the pain caused by his service-connected low back, knees, and ankle disabilities, he can no longer exercise or talk his large dog for walks.

Although obesity, ordinarily, is not a condition for which service connection may be granted, obesity may qualify as an "intermediate step" between a service-connected disability and another current disability. See VA. Gen. Coun. Prec. 1-2017; see also Garner v. Tran, 33 Vet. App. 241, 247 (2021); Walsh v. Wilkie, 32 Vet. App. 300, 305-307 (2020); see also Adams v. Collins, 38 Vet. App. 273, 284 (2025) (July 8, 2025) (holding that obesity may be a disability for purposes of section
talk his large dog for walks.

In a secondary service connection claim, a theory of obesity as an intermediate step is raised when there is some evidence in the record which draws an association or suggests a relationship between the Veteran's obesity, or weight gain resulting in obesity, and a service-connected condition. Garner, 33 Vet. App. at 247-49.

In determining whether the Veteran may be granted service connection for sleep apnea due to his service-connected low back disability, the Board should consider (1) whether the service-connected low back disability caused the Veteran to become obese; (2) if so, whether obesity, as a result of the service-connected low back disability was a substantial factor in causing the claimed secondary disability, sleep apnea; and (3) whether sleep apnea would not have occurred but for obesity caused by the service-connected low back disability. Id.

For the reasons discussed below, the Board finds that entitlement to service connection for the Veteran's OSA due to his service-connected low back disability, with obesity as an intermediary step, is warranted.

The Veteran meets the first criteria of secondary service connection - the Veteran has a current disability. In a March 2025 VA examination, the VA examiner diagnosed the Veteran with obstructive sleep apnea.

As noted above, the Veteran is already connected for low back disability. Thus, the remaining question for the Board is whether the Veteran's OSA is proximately due to or the result of or aggravated by his service-connected disability.

In a September 2025 opinion, the VA examiner opined that the Veteran's OSA is less likely than not proximately due to or the result of the Veteran's service-connected back disability. The examiner stated that obstructive sleep apnea is characterized by recurrent collapse of the pharyngeal airway during sleep, resulting in substantially reduced or complete cessation of airflow despite ongoing breathing efforts and that the records show other significant contributors to the Veteran's OSA, such as his advancing age as well as his morbid obesity as this causes the deposition of fatty tissues along the oropharyngeal route leading to airway obstruction during sleep versus claimed service connected conditions above.

The examiner further opined that the Veteran's OSA was less likely than not aggravated beyond its natural progression by the veteran's service- connected low back disability, stating that there is no pathophysiologic or biochemical link available that the veteran's service-connected musculoskeletal conditions would cause airway obstruction during sleep.

The examiner acknowledged that obesity plays a major role in the development of OSA but stated that obesity results from personal lifestyle choices leading to calorie intake in excess of daily energy requirements regardless of physical activity and that weight loss and gain is not limited to physical activity alone.

In a December 2025 private opinion, an examiner opined that Veteran's sleep apnea is at least as likely as not related to his military service, stating that this opinion is based on the onset of chronic back pain and subsequent development of obesity both independent risk factors for the eventual developments of sleep apnea and considering their persistence after service, and the lack of any more likely alternative cause after considering his other risk factors.

The examiner stated that studies show that 13.8 percent of patients with chronic spinal pain have OSA, with prevalence rising to 16.3 percent in those with combined back and neck pain and exceeding 32 percent in morbidly obese patients. The examiner stated that a review of the research reveals that OSA is strongly associated with both obesity and chronic back pain, and these relationships are often bidirectional.

In a December 2025 post hearing memorandum, the Veteran's attorney argued that the Veteran is entitled to service connection for his sleep disability, as this condition was caused by or related to his military service. The Veteran's attorney cited and provided a 2014 study regarding misconceptions of obesity. Jean-Philippe Chaput, et al., Widespread Misconceptions About Obesity, 60 Canadian Family Physician 11, 973 (2014). The attorney argued that, based on the research, the VA
32 percent in morbidly obese patients. The examiner stated that a review of the research reveals that OSA is strongly associated with both obesity and chronic back pain, and these relationships are often bidirectional.

In a December 2025 post hearing memorandum, the Veteran's attorney argued that the Veteran is entitled to service connection for his sleep disability, as this condition was caused by or related to his military service. The Veteran's attorney cited and provided a 2014 study regarding misconceptions of obesity. Jean-Philippe Chaput, et al., Widespread Misconceptions About Obesity, 60 Canadian Family Physician 11, 973 (2014). The attorney argued that, based on the research, the VA examiner erred in finding that the Veteran's obesity resulted solely from excessive caloric intake without giving adequate consideration to other contributing factors such as insufficient sleep and lack of physical activity.

In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. Id. at 303-04.

The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006).

The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions.").

Here, the Board finds the December 2025 private opinion to be the most probative evidence of record due to its detailed rationale and thorough review of the record. See Nieves-Rodriguez, 22 Vet. App. at 304 ("most of the probative value of a medical opinion comes from its reasoning").; Stefl, 21 Vet. App. at 124.

The Board has considered and weighed the evidence of record. The competent and credible evidence is at least approximately balanced in favor of the Veteran, and benefit of the doubt doctrine applies. 38 U.S.C. § 5107 (b); see Lynch, 21 F.4th 776. The Veteran's OSA is proximately due to his service-connected low back disability with obesity as an intermediary step. As such, the last prong of secondary service-connection is met.

As such, after resolving all reasonable doubt in the Veteran's favor, the Board finds that service connection for OSA due to his service-connected low back disability is warranted. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310.

As the Board has granted service connection on a secondary basis, no further theories of service connection will be discussed.

2. Service connection for insomnia is granted.

The Veteran seeks service connection for a sleep disorder due to his low back disability. During the December 2025 hearing, the Veteran testified that, after he fell and hurt his back in service, he started having irregular sleep pattens and difficulty sleeping. The Veteran further testified that he now has so much pain that he cannot sleep but a couple of hours. The Veteran further testified that he has insomnia because he does not have a CPAP machine and that he is worried that he will have a heart attack in his sleep due to not using his CPAP while sleeping.

For the reasons discussed below, the Board finds that entitlement to service connection for the Veteran's insomnia due to his service-connected low back disability is warranted.

The Veteran meets the first criteria of secondary service connection - the Veteran has a current disability. During
the December 2025 hearing, the Veteran testified that, after he fell and hurt his back in service, he started having irregular sleep pattens and difficulty sleeping. The Veteran further testified that he now has so much pain that he cannot sleep but a couple of hours. The Veteran further testified that he has insomnia because he does not have a CPAP machine and that he is worried that he will have a heart attack in his sleep due to not using his CPAP while sleeping.

For the reasons discussed below, the Board finds that entitlement to service connection for the Veteran's insomnia due to his service-connected low back disability is warranted.

The Veteran meets the first criteria of secondary service connection - the Veteran has a current disability. During a May 2025 VA examination, the Veteran was diagnosed with insomnia disorder and unspecified schizophrenia spectrum and other psychotic disorder.

As noted above, service connection is in effect for low back disability. Thus, the remaining question for the Board is whether the Veteran's insomnia is proximately due to or the result of or aggravated by his service-connected disability.

In a May 2025 VA opinion, the VA examiner stated that it is not possible to determine the impact of the Veteran's back issues on his insomnia, as the Veteran has been diagnosed with various physical conditions and mental disorders that could significantly impact his sleep. The examiner further stated that it is not possible without considerable speculation to determine one singular condition that impacts his sleep more than any others, and that it is also less likely than not that his sleep is impacted by one condition and more likely that the combination of symptoms all impact his sleep.

The Board interprets the March 2025 VA opinion to state that the Veteran's service-connected back disability caused, at least in part, the Veteran's insomnia. Spicer.

Further, the Board notes that the Veteran is competent to report the onset of his symptoms and describe their effects upon his functioning, and the Board finds the Veteran reports to be credible. See Jandreau, 492 F.3d at 1376-77.

The Board has considered and weighed the evidence of record. The competent and credible evidence is at least approximately balanced in favor of the Veteran, and benefit of the doubt doctrine applies. 38 U.S.C. § 5107 (b); see Lynch, 21 F.4th 776. The Veteran's insomnia is proximately due to his service-connected low back disability. As such, the last prong of secondary service-connection is met.

As such, after resolving all reasonable doubt in the Veteran's favor, the Board finds that service connection for insomnia due to his service-connected low back disability is warranted. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310.

STEVEN D. REISS

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board B. Mountjoy, Associate Counsel

The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.

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